Healthcare workforce gains seen with Medicare-funded test program

An increase in government funding for clinical training opportunities for advanced practice registered nursing (APRN) is a feasible and affordable way to grow the primary care workforce, according to a Report to Congress on the Centers for Medicare and Medicaid Services (CMS) Graduate Nurse Education Demonstration.

The $200 million initiative was started in 2012 to determine if Medicare funding for graduate clinical education for APRNs, similar to residency training for physicians, could help meet meet the health needs of the U.S. population.

CMS awarded funding for clinical training programs to five hospitals, which then partnered with accredited schools of nursing and non-hospital community-based care settings to deliver primary, preventive, and transitional care to Medicare beneficiaries.

The five hospitals are Duke University Hospital in Durham, North Carolina; Hospital of the University of Pennsylvania, Memorial Hermann-Texas Medical Center in Houston, Rush University Medical Center in Chicago, and HonorHealth Scottsdale Osborn Medical Center in Arizona.

Lori Hull-Grommesh, director of demonstration at Memorial Hermann-Texas Medical Center, commented on program results in the Texas Gulf Coast area, noting that 95% of APRN graduates are employed in the community setting and are helping meet critical access needs. She said she believes that national funding would allow these results to be replicated in other states.

The report stated that demonstration schools had significantly greater APRN enrollment and graduation growth than comparison schools. It also touched on financial incentives: clinical training for an APRN came to a total of $30,000 compared with $150,000 for just 1 year of community-based residency training for primary care physicians.

Although the GNE demonstration is slated to conclude at the end of June 2018, the five hospitals are currently collaborating with major national stakeholders in order to promote permanent funding to roll out the program nationally.

Aiken noted that various types of healthcare organizations, including physician practices and retail clinics, are hiring nurse practitioners in larger numbers and supporting efforts like the demonstration to increase the supply for advanced practice nurses. Also, healthcare settings are working to recruit more advanced practice nurses, especially for their valuable role in ending the opioid epidemic and addressing unmet mental healthcare needs, she pointed out.

According to Joyce Knestrick, PhD, C-FNP, APRN, FAANP, President of the American Association of Nurse Practitioners (AANP), Congress recently passed and President Trump signed “a comprehensive package of anti-opioid bills into law with a key provision permanently authorizing NPs to prescribe Medication-Assisted Treatments (MATs), further expanding patient access to these critical treatments.”

This passage is extremely important to those fighting opioid addictions as well as those health care workers who are treating them. “Recognizing the ongoing impact of the opioid crisis, Congress and the President moved quickly to get this critical legislation across the finish line. We applaud their actions, which acknowledge the vital role nurse practitioners play in treating patients with opioid use disorder with Medication Assisted Treatments (MATs),” says Knestrick.

What does this mean for the health care community? Knestrick answered questions to explain.

Why is this important—both for NPs and for opioid addicts?

First and foremost, for the millions of American families struggling with addiction today, passage of this legislation ensures patients continuity of care, knowing that their NPs can continue to provide their loved ones access to MAT treatment.

Second, knowing that NPs are now permanently authorized to prescribe MAT, we anticipate significant growth in the number of America’s NPs who will become waivered to prescribe MATs—which will help turn the tide of opioid addiction in communities nationwide.

How will this help more opioid addicts?

As primary care professionals, NPs really are on the front lines of combating the opioid epidemic. Tragically, eighty percent of patients addicted to opioids don’t receive the treatment they need, due in part to health care access challenges, stigma, cost, and other factors. Thanks to advances in Medication-Assisted Treatment—which combines medications that temper cravings with counseling and therapy—and this new law granting NPs permanent authority to prescribe MATs, the opportunities to reach and treat patients struggling with addiction are better than ever before.

In addition to helping addicts, will this make the process more cost-effective? If not, how else will it be beneficial to health care facilities and/or treatment centers?

We do know that treating people with addiction to opioids and other substances is costly—in part because of the need for in-patient treatment and more frequent hospitalizations. Yet, most people in need of treatment simply don’t receive it. As a nation, we are facing significant shortages of specialty treatment facilities for addiction, and this makes it all the more important to ensure that NPs and other primary care providers have the tools to meet the patient need for MATs

AANP has formed a collaborative with the American Society of Addiction Medicine and the American Association of Physician Assistants to provide the 24-hour waiver training for NPs and physician assistants. We invite NPs to visit AANP’s CE Center at https://www.aanp.org/education for more information.

The emergency department (ED) presents a set of unique challenges for patient care, not the least of which is unstable patients who are at great risk for falls. I once heard a nurse educator proclaim: “Everyone is a fall risk in an ED.” From the elderly to the acutely ill, most patients in the department are at possible risk of falling, whether due to their age, their complaint, or the medications and treatment they are receiving. Additionally, many EDs do not have bed or chair alarms available for gurneys to assist with patient falls. Fall prevention is almost solely in the hands of the busy ED nurse.

Here are six ways you can help prevent patient falls in the emergency setting.

1. Use universal falls precautions.

All patients—from the 30-year-old with abdominal pain to the 65-year-old post–total knee replacement—are at risk of falling. In your own practice, using universal falls precautions can be helpful. Treating all patients as though they have the same risk for falls is a good start. Additionally, performing individual fall risk assessments on each patient at the beginning of his or her visit is important to both assessing risk and documenting that risk in the medical record. If completing a falls risk assessment is not mandatory at your facility, consider printing out the Morse Fall Scale and attaching it to your ID badge for quick reference. A standardized tool can help you quickly quantify the risk of patient falls so you can intervene accordingly.

2. Plan your interventions.

My personal favorite fall prevention intervention is the call light. On patient care whiteboards in the ED rooms, I write my name and the phrase, “Please use your call bell for ANY reason” on the board. I orient patients to the call bell immediately and make sure that it is in reach. I explain to them why both side rails need to stay up. Additionally, you may place fall risk socks (or grippy non-skid socks) on your patient as soon as you get them undressed into a gown. Use a fall risk yellow arm band if they’re available to you.

3. Orient your patient.

“I’m going to be your nurse today, and the best way we can work together is for you to help me keep you safe.” I remind patients that even if they feel fine, that trying to get up after laying down or after receiving high-risk pain medications can cause them to feel weaker or dizzier than they might imagine. I encourage patients to use the call bell so I can help assist them out of bed for any reason, but it is also important to set expectations. “It may take me a few minutes to respond, but I will be there as soon as I can.” Try to point out IV lines and oxygen tubing to patients as well as their EKG cables and monitoring leads to remind them that they will need to stay in bed and cannot get up without assistance.

4. Active toileting.

One of the biggest reasons that patients fall is because they have to use the bathroom. For male patients I always place “just in case” urinals at the bedside, and I encourage female patients to use the call bell as soon as they think they have to use the restroom. It is also recommended that you offer toileting as frequently as possible so that you are able to prevent the “have to go right now” urge that draws patients out of their beds.

5. Teamwork works.

It would be impossible for a nurse to be able to be in all of his or her patients rooms at all times, especially within the environment of the ED. If you have a patient who is a high fall risk, who perhaps has dementia or is uncooperative, notify your charge nurse and your colleagues on the unit. Try to move the patient to a room in sight of the nurses’ station or near a hallway. Keep the curtains to the room open if possible to allow as much sight as possible from passersby. If staffing allows, perhaps you could request a safety sitter to help watch the patient to keep them safe.

6. Speak up.

If there are conditions on your unit that continually put patients at risk for falls, report them to your manager and supervisors. It is everyone’s responsibility to help prevent patient falls.

Prior to the 1950s, neonatal jaundice was a common problem and one of the leading causes of death in premature infants — that is, until a British nurse made a fortuitous discovery.

Sister Jean Ward, whose reputation for excellence in rearing puppies landed her a job running the preemie unit at Rochford General Hospital in Essex, England, was a “keen” believer in the restorative effects of fresh air and sunshine and on warm days would wheel the frailer infants into the hospital’s sunny courtyard.

Not wanting to raise any eyebrows with her unorthodox practice, Ward would usually scurry the babies back inside to their incubators before the hospital’s pediatricians made their rounds.

But one afternoon in 1956, Ward ushered a group of doctors over and sheepishly showed them the preemie in her care. The infant was pale yellow from head to toe, except for one deeply bronzed triangle of skin.

Mystified, one of the doctors asked if she had painted that portion of the baby’s skin with iodine. It wasn’t a paint job, Ward assured him. The darker patch of jaundiced skin had been covered up by the corner of a sheet while the infant was outside. It was the rest of the infant’s yellowish skin that had faded, she explained, apparently from the sun exposure.

Ward’s astute observations helped to pave the way for phototherapy treatments that are still used today to treat infants suffering from hyperbilirubinemia — and she’s just one of many nurses whose bedside discoveries have revolutionized the way we care for patients.

Other groundbreaking nurse inventions, as noted in this 2014 Medscape article, include everything from disposable sanitary napkins to crash carts to ostomy bags to disposable baby bottles. It was also a nurse, who in 1911, created the first mannequin to function as a patient simulator for nurses in training — and newer generations of nurse inventors and researchers are tackling other vexing problems in health care.

With hospital-acquired infections on the rise, Ginny Porowski worried about the health hazard created by waste bins overflowing with contaminated isolation gowns — a common sight on any floor with patients on contact precautions. So a few years ago, the North Carolina nurse invented a new type of gown that can be disposed of more easily. Unlike the typical isolation gear, Porowski’s GoGown has a special inside panel allowing the wearer to wrap a used gown into a small, compact bundle for safer disposal. Health care providers never have to touch the outside of the gown and used bundles sink to the bottom of the trash container, rather than billowing out the top.

A Chicago-area nurse’s research, meanwhile, is changing the way some Illinois hospitals approach newborns’ first baths.

Courtney Buss, an RN at Advocate Sherman Hospital in Elgin, Illinois had been hearing a lot of buzz about the benefits of delaying a newborn’s first bath for at least eight to 24 hours, but she was unable to find much in the way hard evidence supporting the “wait-to-bathe” approach. Looking for answers, she decided to conduct her own investigation.

At most hospitals, newborns typically receive a sponge bath soon after birth to remove the white, waxy, cheese-like substance called vernix caseosa that covers their body. But Buss’s 2016 study showed that leaving the protective layer of vernix intact for at least 14 hours can dramatically reduce bouts of hypothermia and hypoglycemia in newborns.

Over the course of nine months, as bathing was delayed, Buss found that the percentage of infants suffering from hypothermia dropped from nearly 30% to 7% and hypoglycemia rates plummeted from 21% to 4%, according to the Chicago Tribune. Delayed bathing also dramatically improved breastfeeding rates among the babies because the vernix helps neonates pick up on their mother’s scent, which makes latching easier.

The hospital system where Buss works has since instituted a “wait to bathe” policy at half its hospitals and her research underscores what the nursing profession has long known — that important discoveries aren’t restricted to those in white lab coats. Innovative scientists also wear scrubs and even answer call bells.

When I tell people I’m a psychiatric and addictions advanced practice nurse, they are a bit surprised after I share with them my family origins. You see, I come from multiple generations of pharmacists, dating back to the turn of the 20th century when my great grandfather patented medicines around the world and maintained company with the founding fathers of Eli Lilly and Johnson & Johnson. My grandfathers, on both sides of my family, my parents, and numerous aunts and uncles also studied and practiced pharmacy.

Nevertheless, I ultimately decided my career path would include a deep understanding and respect for the role of the pharmacist, but I wanted to practice nursing and provide care to patients with psychiatric and substance use disorders. As an advanced practice nurse, I was able to incorporate prescribing into my practice as a master clinician in psychopharmacology.

My extensive connection to pharmacy and pharmaceutical agents, and psychotropic medications in particular, is why I have embraced pharmacogenetic testing for patients who present with complex diagnostic issues and for whom various trials of medications have failed to provide symptom relief and emotional stability.

Genomind’s Genecept Assay is a simple, in-office, cheek swab-based test that I offer to patients to assist with personalizing their psychopharmacological regimen; it’s painless and easy to perform. The assay explores key pharmacokinetic and pharmacodynamic genes, which affect how the patient’s body may metabolize medications and the potential impact the medication may have on the body. This information provides an understanding of whether a drug is likely to either work properly or produce adverse effects for a patient before he or she even tries it. The details provided by the assay also offer insights into the dosing of medications and potential drug-to-drug interactions based on their metabolism by the various CYP450 system enzymes located in the liver.

With this information, along with the patient’s symptom presentation; medical, psychiatric, and substance use histories; family history; and medication (including over-the-counter and supplemental medications) history, I am able to narrow down the pharmacological treatment options so patients can feel better, faster.

In 93% of patient cases, the Genecept Assay influenced clinicians’ decisions about medications. It helps reduce the trial-and-error approach, time, expense and struggle of finding the right treatment options. I think the results of the assay are especially helpful for patients who are frustrated after multiple medication failures when trying to find a medicine to alleviate their symptoms. As a clinician, the more information I have in my toolbox when working with a patient, the better.

An example of the beneficial results received as a result of using genetic testing occurred when I treated a woman who was in her early 60s and who said she had suffered from a lifetime of depression, dating back to her early childhood. The genetic testing helped me realize she was suffering from low dopamine levels, our pleasure enhancing and energizing neurochemical located in the prefrontal cortex of the brain, the area responsible for executive functioning, including motivation, attention, concentration and organization. This was an ah-ha moment for both my patient and me, as it explained why so many past trials of medications were either ineffective or contributed to adverse side effects.

Based on the results of the Genecept Assay and my patient’s history, I prescribed a psychostimulant, typically reserved for the treatment of Attention Deficit Hyperactivity Disorder. Once dosed to the appropriate level with guidance from the pharmacokinetic results of the assay, it revolutionized her life; the depression lifted and her quality of life improved dramatically for the first time she could recall. Now, at the age of 70, she remains free of depression and is catching up on the life that depression stole from her for so many years.

An important point to emphasize is that the test is neither directive nor diagnostic. For those prescribing advanced practice nurses and other clinicians who may feel challenged by interpreting the results of genetic testing, I can assure you it’s well within your ability to do so and that the companies who offer the testing have extensive clinical support teams to guide you through the results and pharmacological decision-making process. I will also point out that genetic testing to personalize medication decisions is not a new science, as oncology clinicians have been utilizing such reports for years to personalize chemotherapy regimens for their patients.

As health care and the disciplines of psychiatry and addictions continue to evolve, personalized medicine will become more and more the norm. Advanced practice nurses have an opportunity to serve in a critical and leading role during this emerging period by adding pharmacogenetic testing to assist in streamlining psychotropic medication options for their patients. Genetic testing is one of the keys to unlock the mysteries of prescribing psychotropic medications and should be added to the clinician’s arsenal of clinical tools in order to to maximize improvement in symptom relief and quality of life for our patients.

Perhaps you give CPR (cardiopulmonary resuscitation) almost every shift, and you consider yourself a code blue champion. Maybe you work on a med-surg unit or in a surgery center that rarely has to code a patient. Despite the ACLS (Advanced Cardiac Life Support) certification card in your wallet, you may find your skills need brushing up on. Below are some tips for ensuring that you are providing excellent CPR.

1. Get your hands on the chestquickly.As soon as you notice that a patient is pulseless, place your hands on the chest to start compressions while yelling for others to help. Minimize interruptions to CPR.

2. Use your equipment.
If possible, use a stool so that the compressor is at the proper height, and also place a backboard or use the backboard setting on a mattress to get the proper resistance for compressions.

3. Go fast, but not too fast.Occasionally compressors get so full of adrenaline that they compress at a rate of 120-150, which is too fast to allow for ventricular filling. The rate should be between 100-120. Tip: Music services such as Spotify actually have entire playlists created for the ideal rate of CPR!

4. Depth is important.Get the proper depth to allow full recoil of the chest. The recommended depth for adults is 2 to 2.4 inches. Sometimes this may mean lifting your hands completely off the chest after each compression.

5. Too much of a good thing.
Pause for breaths without an advanced airway, but also be careful not to “overbag” the patient. Excessive ventilation can increase intrathoracic pressure and decrease coronary perfusion pressure.

6. Use end tidal to measure your compressions.
End tidal carbon dioxide monitoring can reveal the quality of your compressions. End tidal greater than 20 is associated with greater survival outcomes. Values of less than 20 indicate that you need to adjust your rate and depth. If end tidal suddenly jumps into the 40s, you likely have return of spontaneous circulation.

7. Switch compressors to combat fatigue.
Proper CPR is exhausting. Switch every two minutes, and you can give epi every two compressors.

8. Designate a CPR coach.
If you have extra eyes or hands, designate a CPR coach who will monitor the depth and rate of compressions and who will help ensure that compressors are switching appropriately and end tidal is appropriate.